Managing Radiation Oncology Billing Chaos

From my experience in the clinic, I offer a candid confession: billing was not my strong suit. That’s an understatement, of course. For me, there were too many rules. From the clinical standpoint, those rules didn’t always seem to align with what was best for the patient, which caused frustration and consternation.  Also, with no formal training in billing, I was the furthest thing from being an expert in the subject, and I frequently had to ask about what I could bill, and  when I could bill.

This is more the rule than the exception, with most clinical team members learning about billing best practices on the job. With constantly changing guidelines, keeping up can be challenging, even for those with coding acumen. But as confusing as billing can be, what’s more befuddling is that we have access to technology and automation to systematize and improve all sorts of clinical processes from contouring to optimization. Why aren’t we applying those same systems to billing?

The Perfect Storm

At present, our field is experiencing a number of challenges that put financial pressure on departments across the country:

• Skill Gaps: According to a 2015 Lancet Oncology study, the global skills gap by 2035 is projected to be in excess of 22,000 radiation oncologists and 29,000 medical physicists. 
• Staffing Shortages, Increased Costs: A whopping 93% of doctors in 2023 admitted their practice is facing shortages of key clinical staff according to an ASTRO news release. This contributes to treatment delays, patient delays, and reduced support services. These shortages were perceived as a main driver of increased practice costs, up 23% since the pandemic.
• Declining Reimbursement: While costs continue to climb, reimbursement has steadily fallen. In the last decade, Medicare physician payments have dropped by a total of 25%, more than most other medical specialties. 

These issues layer on top of other practical considerations needed to provide excellent care or compete with others regionally or nationally. These can include capital expenses for new equipment/software, adopting new modalities, or improving existing workflows. In combination, these trends underscore the need for improved transparency and efficiency to keep department finances in the black. 

To further complicate things, radiation oncology stands as one of the most error prone specialties when it comes to billing, at least according to the 2023 annual Comprehensive Error Rate Testing (CERT) audit. The audit, conducted by CMS to measure payments that do not meet Medicare requirements, revealed that a staggering 36% of randomly sampled claims—extrapolated to $330 million in charges nationwide—submitted to Medicare Fee-For-Service program were deemed as improper, largely due to insufficient documentation to support the claims.  

Opportunities For Improvement

The tools used in treatment workflows are relatively sophisticated, yet we lack the proper infrastructure to manage billing codes in a way that minimizes errors and optimizes throughput. Applying error mitigation approaches frequently used for patient safety in a similar manner for billing practices could be an effective strategy in reducing the error rates seen in the literature. 

The hierarchy of effectiveness highlights the phenomenon that some error reduction strategies are simply more effective than others. To wit, interventions such as automation, standardization, and notifications are more reliable than low leverage approaches such as education or policies and procedures. 

The opportunity for optimizing billing practices lies in the top half of the intervention totem.
©2022 Institute for Safe Medication Practices (ISMP)

QuickCode was designed to restore sanity to the billing process using higher-leverage error mitigation strategies. It aims to reduce errors and ensure accurate billing by automating charge analysis for ARIA^® and MOSAIQ^®. Standardized templates based on consensus guidelines provide coding consistency, while a user-friendly interface makes it easy to interpret results to take appropriate action.

With billing, the devil is in the details. For codes to qualify for reimbursement, they must be executed under certain conditions, well-supported with documentation, and involve time-sensitive approvals. For an automated solution to be effective, it has to consider these billing “gotchas:”

• Documentation: Noting the presence, approval, and status of various supporting documentation. With document parsing, QuickCode can also verify important information within the document. 
• Account Numbers: Validating the account numbers assigned to patients that correspond to their course of treatment.
• Approvals: Verifying the existence of the approval of imaging, prescriptions, or documents as well as validating the date of service. 
• Coding Conflicts: Helps avoid simultaneous billing of two or more codes not permitted on the same date of service or same course of treatment.
• And more…
  
  

Real-World Implementation

When fully implemented, QuickCode is a major time-saver for our clinical partners. Whether it’s reducing a lead therapist’s review workload from a full day to just 15 minutes or the ability to verify 65 patients in the time it used to take to check just two, departments are pleased with how QuickCode streamlines their routine billing.

Everyone loves time savings, but how does QuickCode perform with regards to charge reconciliation? Is there a potential benefit to the bottom line? To get a better understanding of general billing practice—as individual practices vary widely—we at Radformation partnered with multiple departments across the country as part of a Pilot Program to investigate their billing practices in hopes of uncovering some industry insights through the lens of QuickCode.  

In this effort, we worked directly with 32 institutions—30 using ARIA® OIS, 2 using MOSAIQ®— ranging from small community practices to large university-based medical centers with multiple linacs and specialty modalities. We retrospectively reviewed a minimum of 90 days worth of charges accumulated from all modalities including SRS, SBRT, 3D, HDR, TBI, etc. Specifically, we looked for missing or extraneous charges associated with these treatments compared with published recommendations. To summarize the results for each department, we generated an ROI Report highlighting gaps in performance, in-depth analysis, and detailed recommendations to improve their billing practices. 

Early Results, Common Issues

Sifting through an average of 137 days of data, we found a significant number of missed charges across the 32 institutions, summing $3.9M over the Pilot Program evaluation periods. In this context, a missed charge was one that was erroneously omitted or somehow not captured in ARIA® or MOSAIQ® compared to templates built in keeping with best guiding practices. On a per-department basis, this amounts to an average of $123k in missed charges (median: $71,500). Extrapolated to an annual basis, missed charges exceeded $325k, on average. Overbilling was also common, with an average of $83k in excessive charges during the period of data review (median: $31,500). 

Upon reviewing billing practices, several common inconsistencies emerged as key contributors to the error totals:

• SRS and SBRT Planning Modalities: For SBRT/SRS courses, facilities can opt for either forward planning or inverse planning. In our Pilot assessments, planning with one technique but billing for the other modality was very common.  Since QuickCode analyzes the digital plan, we can assess the planning modality to determine the types of methods used in planning, upon evaluating plans and charges it's common that facilities are reporting the incorrect modality. 
• Respiratory Motion Management Simulation: Describing the physician work and practice expenses involved in simulating a patient using motion management, this CPT Code (77293) was frequently missed as a part of a patient’s billing record, despite these services being provided.  QuickCode looks for one of three factors to be present to be deemed as billed: a 4DCT performed during the initial simulation, an ITV in the planning structure set, or a MIP/AVG on the plan. 
• Daily Imaging Charges: We identified a few issues among the majority of the facilities we reviewed, including not reporting the charges when imaging was performed, not approving the images prior to the subsequent treatment fraction, or lacking the documentation providing formal physician direction to perform daily imaging.  

Conclusion: It’s Time to Embrace Innovation in Billing
The complexities of billing in radiation oncology demand innovative solutions. Through the adoption of systems and automation, departments can navigate the challenges of billing with greater ease and efficiency. By embracing technology leveraging consensus guidelines, we can pave the way for a more sustainable and resilient future for our departments. 

The results of these systems speak for themselves; the data from the Pilot studies show significant numbers of missed and overbilled charges across multiple institutions. Departments that have implemented QuickCode have reported significant time savings and increased confidence in their billing accuracy. By automating mundane tasks and providing real-time insights, QuickCode empowers staff to focus on delivering quality care while ensuring financial viability.

To learn more about how QuickCode fits in your department or to discuss participating in the Pilot Program, click on the calendar below to schedule a demo.